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Full text of "Mental Health Issues and Priorities"

DEPARTMENT OF 



I^^ENTAL GUBERNATORIAL 
WEALTH CANDIDATE 

BRIEFING 



MENTAL HEALTH 
ISSUES AND PRIORITIES 



Prepared in May 2008 by 

The IVIissouri IMental Health Commission 

Dr. Ron Dittemore, St Joseph, Chair 
Dr. Patricia Bolster, St Louis Ms. Kathy Carter, Four Seasons Ms. Beth Viviano, St Louis 
Rev. Phillip McClendon, Joplin Dr. David Vlach, Kansas City Ms.Joann Leykam, St Charles 





TOPIC 


PAGE 


1. 


Introduction 


2 


II. 


Critical Points 


3 


III. 


DMH Overview 


4 


IV. 


Four Major Issues 


6 


V. 


Mental Health Transformation 


10 


VI. 


Recent Achievements 


11 




I. INTRODUCTION 



The Missouri Mental Health Commission is a Governor-appointed, non 
partisan, seven-member board statutorily established (Chapter 630.003, 
RSMO) with executive and policy oversight for the Missouri 
Department of Mental Health (DMH). 

During times of gubernatorial transition, the Commission provides 
information to candidates, without consideration of political affiliation, 
regarding the DMH mission, its programs, key issues and a vision for 
Missouri mental health in the future. 



Commission members and DMH staff 
are available for discussion about the 
contents of this document or mental 
health issues in general upon any 
candidate 's request, which should be 
made at the following e-mail site: 
MHCommission@dmh.mo.Qov 



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II. CRITICAL POINTS 



1. The Department of Mental Health (DMH) proudly serves over 170,000 
Missourians with mental illness, developmental disabilities, and addictions. 

It is a safety net for the state's most vulnerable citizens and their families. 

2. Only about 5% of DMH consumers are served in state-operated facilities. 

Most are served through 1,600 contracts with community-based providers. 
DMH employs about 8,800 professionals and other workers, while its 
contractors employ over 30,000 Missourians. 

3. DMH has heavily leveraged state dollars to draw federal match through MO 
HealthNet and federal grant programs in order to optimize resources. In fact, 
only 53% of the department's $1.1 billion budget is General Revenue. 

4. Too many citizens cannot access DMH services. Each of the Department of 
Mental Health's three operating divisions has long waiting lists for services and 
supports. Every name on a waiting list is a potential tragedy. 

5. Missouri's mental health workforce is critically low. There are not enough 
mental health professionals or direct care staff to fill positions in state -run 
facilities or contracted community agencies. High turnover rates at all levels, 
from physicians to food service workers, threaten the safety of consumers and 
staff alike. 

6. Contracted community provider reimbursement rates have lagged far 
behind inflation. Providers struggle to meet costs for food, fuel, insurance, 
and proper staffing. 

7. State-run psychiatric facilities continuously operate above patient capacity. 

Long-term care facilities and the sexual offender treatment center are 
particularly strained in that there are inadequate (or absent) community 
alternatives along with limited ability to control admissions and discharges. 



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III. DMH OVERVIEW 



A. DMH MISSION (RSMO Chapter 630.020) 

1. Prevention: Reduce the prevalence of mental disorders, developmental disabilities, 
and drug abuse; 

2. Treatment: Operate, fund, and license modem treatment and habilitation programs 
provided in the least restrictive environment; and 

3. Improve Public Understanding: Improve public understanding and attitudes 
toward mental illness, developmental disabilities, and addiction. 



HOPE 



MISSOURI DEPARTMENT OF 



MENTAL 
HEALTH 




OPPORTUNITY 



COMMUNITY INCIUSION 



B. DMH VISION Missourians receiving mental health services will have the 
opportunity to pursue their dreams and live their lives as valued members of their community. 



a DMH DIVISIONS AND OFFICES 
Divisions of: 

• Alcohol and Drug Abuse (ADA) -RSMo Chapter 631 

• Comprehensive Psychiatric Services (CPS) —RSMo Chapter 632 

• Mental Retardation and Developmental Disabilities (MRDD) —RSMo Chapter 633 

Office of Comprehensive Child Mental Health -RSMo 630.1000 
Office of Transformation - Governor appointed and time limited 



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D. DMH CONSUMERS 

DMH served 171,208 people in community settings and 8,748 in institutional settings in FY 
2007 (duplicated counts). 

• Adults with severe mental illness and children with severe emotional disorders 

• People with developmental disabilities 

• People with substance abuse and gambling disorders 

• Sexually violent predators 

About half of the individuals served by DMH are Medicaid eligible. 



E. DMH FUNDED AND OPERATED PROGRAMS 

Annual budget: $1.1 billion: 53% GR, 43% Federal, 4%) Other Funds 

DMH generates $185 million per year in reimbursements from Medicaid, Medicare and other 
third party pay, as shown below (does not include the $92 million disproportionate share payments [DSH] 
retained by the Department of Social Services): 



Medicaid/DSH: 
Medicare: 

Other 3"^ party/client pay 



$160,503,768 
$14,355,763 
$ 10,001,548 



Amount of State General Revenue that matches Medicaid entitlement services: $157,028,754 
(does not include DMH GR that generates $134 million in DSH payments to DMH and DSS). 

Community-Based Contractual Services: 

DMH contracts with over 1,600 providers employing 30,000 people statewide. 



State-operated services: 8,800 state employees 

9 state psychiatric facilities for adults 

2 state psychiatric facilities for children 

6 MRDD habilitation centers, 1 1 regional centers 

Certification and Licensure: 

> Certities 674 community providers. 

> Licenses 405 community facilities and programs. 



• Community-based services 
contracts are 67%) of total 
budget and serve 95% of 
DMH consumers. 

• State operated services are 
27% of the total budget and 
serve 5% of DMH consumers. 




Lack Timely 



1. Missourians 



• Due to lack of adequate funding, DMH-contracted 
community mental health centers (CMHCs) turn away 2,000 
people per month in need of mental health treatment who are 
without insurance or MO HealthNet coverage. 



Access to Mental 



Health Services 



• Most DMH psychiatric hospitals typically operate at 
108-1 15% over census. Western Missouri Mental Health 
Center's emergency room has been on diversion for 360 of 
the last 365 days. 



• Only 8% of the estimated 485,000 Missourians with substance abuse problems were treated 
by the Division of ADA in FY 2007. A snapshot of waiting lists on one day in 2007 found 
over 3,000 people waiting for ADA services. 

• One in 150 Missouri children will be diagnosed with Autism. 

• MRDD case managers have caseloads as high as 70 clients in many areas of the state. 

• 4,000 eligible individuals still await MRDD in-home or community residential services. 



• On average, Missourians with serious mental illness die 25 years earlier than the general 
population; 60% will die from a chronic medical condition, not from self-harm. 

• Missourians with developmental disabilities die 12-16 years earlier than the general 
population. 

• 25% of all U.S. community hospital admissions for adult patients involve serious mental 
illness and substance abuse. 

• 16% of all Department of Corrections (DOC) inmates are diagnosed with mental illness, and 
85%) have substance abuse problems. 



IMPACT: 



6 



2. State 



• State psychiatric facilities are seriously overcrowded 
because of few community alternatives and limited ability to 
control admissions and discharges. 



Psychiatric 



Seriously 



Facilities are 



Overcrowded 



• Courts control 7 of 10 admissions to DMH long term 
care state hospital beds [Incompetent to Stand Trial (1ST), 
Not Guilty By Reason of Insanity (NGRI), or sexual 
predators (Missouri Sexual Offender Treatment Program — 
MOSOTC)]. 



• Courts also control forensic discharges from state 
facilities to community settings or jail for individuals found 
competent to stand trial for an alleged crime. 



"If we cannot control the front end or the back end of our institutional services, 
our only choices are to add more beds and resources or dilute the quality of care 
until we experience crises in safety for patients and staff " 

— Dr. Joe Parks, DMH Medical Director and 
Director, Division of Comprehensive Psychiatric Services 



• Overcrowding of State Facilities: State psychiatric hospitals operated at 108-1 15% 
capacity in FY 2007. 

• Client Injuries: In the past year there were 5,244 injuries requiring at least first-aid to 
clients in DMH facilities; 633 of these required medical intervention beyond first-aid. 

• Staff Injuries and Workers Compensation: For Fiscal Years 2005 (1,559), 2006 (1,718) 
and 2007 (1,756), DMH staff reported a total of 5,033 injuries to Worker's 
Compensation. Of these, 60% were client related. 



IMPACT: 



7 



3. Workforce Shortage and Low Reimbursemen t Rates Pose 
Significant Challenges to Care and Safety 

• Department-wide (State Psychiatric Hospitals and MRDD Habilitation Centers) vacancy 
and turnover rates in key direct care and clinical staffing positions: 



Staff Position 


Annual Turnover Rate 


Direct Care 


25.65% 


Psychiatrist 


24.14% 


Psychologist 


20.25%, 


Nursing 


27.90% 



• DMH contracted community providers serve 95% of all DMH consumers. Over the last 
15 years, community provider rates have not kept pace with inflation. Community 
providers cannot compete with the private sector or even state salaries. Costs of 
medicine, food, transportation and communication far exceed inflation rate adjustments. 

• Disparity examples: State employee COLAs (salary and fringe) increased 49.7% 
between fiscal years 1999 to 2008 compared to 1 1.6% for ADA provider COLAs, 1 l.P/o 
for CPS provider COLAs, and 30% for MRDD provider COLAs. 

• Federal reimbursement rates for Federally Qualified Health Centers (FQHCs) for many 
behavioral health services are nearly twice that received by community mental health 
centers. 

IMPACT: 

• Facility staff overtime is too high. DMH paid overtime trends: $11 million in FY 05 to 
$13 million in FY 07. 

• Facility staff morale is low due to mandatory overtime and a feeling that nothing is 
improving. 

• Facility direct care staff view their positions as dead-end jobs with no career 
advancement opportunities. 

• Facility sick leave is too high, with some staff manipulating Family Medical Leave. 

• Contracted community providers are in much the same predicament: 

- Unable to compete with private sector for professionals and direct care workers 

- High turnover, low morale 

- Unable to keep pace with rising food, fuel, and insurance costs 



8 



4. Inadequate 
Resources for 



• DMH must transform its current system from 
crisis-driven care toward a public health approach that 
emphasizes wellness, prevention, disease management, 
and early intervention. 



Wellness, 



• Missouri's autism treatment services for young 
children must be greatly expanded, in collaboration with 
school-based autism services. 



Prevention, and 



Early Intervention 



• Missouri lacks full insurance parity for the 
treatment of either mental illness or addiction, and there is 
an urgency from families seeking insurance coverage for 
autism-related services. 



Employment opportunities are 



scarce for DMH consumers. 



- Persons with serious mental illness and developmental disabilities generally live in 
poverty. 

- Only 16.5% of individuals with serious mental illness worked during 2006. 

- There is a 40% gap between the employment rate of adults with disabilities and those 
without disabilities. Half of Missouri's homeless have serious mental illness or 



• Current system is limited to costly "deep-end" behavioral services available only to the 
sickest Missourians, predominately individuals that are MO HealthNet eligible. Disabled 
recipients are among the most expensive of the MO HealthNet program. 

• All three operating divisions have long waiting lists for services. Those lists could be 
reduced with proper preventive services and early intervention. 



addiction. 



IMPACT: 



V. MENTAL HEALTH TRANSFORMATION 



• In October 2006, Missouri received a five-year grant from the federal Substance Abuse and 
Mental Health Services Administration (SAMHSA) Mental Health Transformation State 
Incentive Grant program to develop and implement a comprehensive plan to transfr)rm the 
mental health system in Missouri. 

• Executive Orders 06-39 and 07-15 established the Transfr)rmation Working Group (TWG), 
comprised of consumer and family leaders and public leaders from the executive and judicial 
branches. 

• Staff based in the Department of Mental Health (DMH) led the planning process in 
partnership with other state agencies involved with mental health services. 

• The Comprehensive Plan, submitted to SAMHSA in March 2008, is designed to move 
Missouri's mental health system toward a public health approach. It addresses mental health 
services and access across systems, age groups, cultures and regions. 

• The common agenda that emerged to achieve the shared vision and move Missouri toward a 
public health approach resulted in six strategic themes: 



From: 




To: 


CULTURE OF CRISIS/ 
RISK OF HARM 




CULTURE OF HOPE/ 
FIRST.. ."DO NO HARM" 


"NOWHERE TO GO" 




EASY, EARLY AND 
EQUAL ACCESS 


DISABILITY FOCUS 




WELLNESS FOCUS WITH 
PREVENTION AND EARLY 
INTERVENTION 


BUREAUCRACY/ 
PROVIDER DRIVEN CARE 




CONSUMER DIRECTION 
AND EMPOWERMENT 


"POCKETS" OF 
EXCELLENCE 




UNIVERSAL BEST 
PRACTICES 


FRAGMENTED& 
CENTRALIZED SYSTEM 




SHARED OWNERSHIP & 
INVESTMENT 

(STATE-LOCAL, PUBUC-PRIVATEy 



10 



VI. RECENT ACHIEVEMENTS: Highlights from 
FY 2005 - 2007 



1. CHILDREN RETURNED TO MOTHERS' CUSTODY: 246 children were returned to their mothers' 
custody through ADA's specialized CSTAR substance abuse programs for women with children. 

2. DRUG-FREE BIRTHS: 266 drug-free babies were bom to pregnant drug-addicted women through 
ADA'S CSTAR programs. 

3. CUSTODY DIVERSION FOR SED CHILDREN : 386 children with Serious Emotional Disorders 
(SED) have been able to remain in the custody of their families and still receive intensive mental health 
services through the — Qstody Diversion Protocol " developed by DMH as part of the Comprehensive 
Children's Mental Health Plan. 

4. MISSOURI DMH/MO HEALTHNET PHARMACY IMPROVEMENT PARTNERSHIP: The 

DMH and MO HealthNet Partnership Initiative improved prescribing practices for psychiatric medications 
for enrollees and saved $36 million per year off projected growth trends. The Initiative is nationally 
recognized and is the only state program to have won the American Psychiatric Association Bronze 
Achievement Award. 

5. WAITING LISTS FOR MRDD SERVICES: More than 847 children and adults with developmental 
disabilities who were previously on the MRDD wait list are now receiving services. 

6. COMMUNITY TRANSITION: MRDD has successfully transitioned 238 individuals to community 
living environments from its six habilitation centers since January 1, 2005. 

7. MISSOURI'S NATIONAL LEADERSHIP IN AUTISM : Missouri is a national leader in the 
development of an Autism Registry through the Interactive Autism Network (lAN)-MO project, a 
partnership between DMH-MRDD, the Thompson Center for Autism, and Kennedy Krieger Institute in 
Baltimore, MD. 

8. CRISIS INTERVENTION TEAMS: 1,500 local police officers statewide have voluntarily participated 
in Crisis Intervention Team (CIT) training, helping them to better respond to persons with mental illness 
and getting them to treatment instead of jail. Officers have made more than 7,400 mental health crisis calls 
with an arrest rate below 5%. 

9. FEDERAL GRANTS: With help from the Missouri Institute of Mental Health (MIMH), Missouri ranks 
8* in the country for competitive grant funding from the Substance Abuse and Mental Health Services 
Administration. 

10. SUICIDE PREVENTION TRAINING: DMH has sponsored training for more than 15,000 Missourians 
to help them recognize suicide risk and to assist people who may be considering suicide get treatment. 



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